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Office of Human Resources

HRIS PAYROLL ADMINISTRATION
Phone: 818) 677-2101
Fax: (818) 677-5870
Mail Drop: 8229
Prior Pay Period Adjustment Form
(Print this form in landscape format)
(Do not use this form for Work-Study Student Pay Requests)
Dept ID
Dept Name Pay Period Month Year
-
I. SELECT TYPE OF "PAY" TRANSACTION ADJUSTMENT:
Prior Month Pay Hours Underpaid Hours Overpaid
Request pay from a prior month when employee's hours were not
reported in regular transmission.
Report underpaid hours from a prior pay period. Report overpaid hours from a prior pay period.
II. SELECT TYPE OF "LEAVE" TRANSACTION ADJUSTMENT:
Post Leave Usage Correct Leave Usage Delete Leave Usage
Post leave usage for a prior month when an employee's leave time
was not recorded during the applicable period.
Correct leave usage for a prior month that was
recorded incorrectly.
Delete leave usage for a prior month that was
entered in error.
CSUN ID
Record #
Employee Name
Job Code
Date
Total Hrs*
TRC


Explanation of Adjustment (required information - please be as descriptive as possible)
* Total Hours: If total hours reported applies to leave usage for a period that covers more than one day, specify actual dates and hours applicable to those dates in the description box. Lump sum leave usage cannot be processed.
I CERTIFY THAT THE INFORMATION ON THIS PAYROLL ADJUSTMENT FORM IS TAKEN FROM THE SPECIFIED TIMESHEET AND/OR ABSENCE REPORT FOR THE PAY PERIOD INDICATED, AND
THAT THE TIMESHEET AND/OR ABSENCE REPORT HAS BEEN CERTIFIED BY SIGNATURE OF THE EMPLOYEE AND THE SIGNATURE OF THAT EMPLOYEE'S SUPERVISOR/MANAGER.

Note: Properly certified and signed timesheets must be maintained on file by the department for five (5) years.
Form Completed By (Print)
Date
Authorized Approver Signature: _______________________________
Print Name
Date
* Payroll Office Use Only *
Date: Batch No: Initials: Total Hours: Total Rate: Agency: 253
SSN: Class: Serial: EID: Date Paid:
PA 115 OHRS-PS (9/2008 - Rev 8/2016) also replaces PA 105